Fit pour Voyager? · • Moderate–severe pulmonic valve regurgitation • Sinus of Valsalva...

Michel White MD, FRCPC(C), FACC, FESC

Fit pour Voyager?

Plan de la Presentation

•  Physiologie et exigences de l’altitude •  Les challenges physiologiques chez le patient a haut

risque: Hypertension, arythmies, cardiopathies et MCAS •  Comment stratifier, quoi recommander? •  Quoi faire avec la medication CV?

Physiologie et exigences de l’altitude

Question 1

Hemodynamic adaptations to high altitude

MW 2008-01 7

La réponse cardiovasculaire en reponse a une exposition aigüe à la haute altitude

•  ↑ FC ~16 bpm à 4000 mètres •  Élévation du débit cardiaque •  ↓ légère des volumes cardiaques •  ↑ FEVG (activation sympathique et ↓ de l’activité

vagale) •  La réponse semble indépendante de l’âge et du

sexe.

Altitude-induced autonomic and CV adjustments

Time course of CV and autonomic changes in high

altitude

Exercise increases O2 desaturation at high altitude

Beneficial/detrimental effects of high altitude adjustments with health and

disease state

MAM leger = 1-3; modere = 4-6 ; severe > 6 points

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MAM – Facteurs favorisants et predisposants

•  Vitesse de montee: max 500 metres/ 24 heures > 3000 m  1 semaine pour atteindre 3000- 5000 metres

•  Femme = homme mais oedeme facial plus frequent •  Plus elevee <18 ans et > 50 ans •  Favorisee par exercise intense •  Sujets obeses et migraineux plus a risque de MAM •  Non reliee = capacitee aerobique, entrainement

physique et tabac

Reponse 1

Les challenges physiologiques chez le patient a haut risque: Hypertension, arythmies, cardiopathies

et MCAS

Question 2

20

IVUS data – Proximal LAD

Lund LH and DM Mancini. Int J Cardiol 2008;125:166-171

Decline in peak VO2 with age in men and women

Main pathophysiologic changes and their interactions with CV

conditions

Prevalence of self-reported CVD among high-altitude mountaineers

Chronic conditions affected by altitude exposure

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Hypertension artérielle et la haute altitude

•  Traitement pharmacologique ? Trop ou trop peu •  ↑ de la T.A surtout systolique

─  ↑ Arythmie ─  Hypertension artérielle nocturne

•  Grande susceptibilité individuelle – Le patient hypertendu est-il à risque d’évènement cardiaque à haute altitude ?

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Les adaptations de la circulation coronarienne

•  Régulation du flot coronarien = fréquence cardiaque, contractilité et tension murale

•  Changement aigü: ─  La réserve de flot coronarien (5 à 6 fois) est

suffisante pour repondre aux demandes physiques élevées en haute altitude

•  Chroniquement: ─  ↓ du flot coronarien comparé au niveau de la mer

(~ 30% altitude des Andes) ─  ↓ de la fréquence cardiaque, polyglobulie, ↑ de la

différence artério-veineuse = identique au changement de la circulation périphérique.

27 MW 03-2006

Impact of hypoxemia and high altitude (5245m) on hemodynamics and gas exchange parameters in healthy climbers

Ghofrani HA, et al. Ann Int Med 2004; 141: 169-177

Systolic blood pressure (mmHg)

Heat rate (bpm)

Saturation (%)

Systolic pulmonary artery pressure (mmHg)

Cardiac output (L/min)

Maximum level of exercise (W)

148.0

76.0

99.0

17.5

6.0

--

Rest Normoxic

232.0

171.0

98.0

25.1

14.4

262.5

Stress

142.5

84.8

72.0

30.5

5.1

--

Rest Hypoxic

209.5

157.3

60.8

42.9

11.1

130.6

Stress

120.0

84.0

83.0

22.0

5.6

--

Rest Sidenafil

185.0

148.5

71.0

27.5

15.1

189.5

Stress

Low altitude High altitude

Categories of Disease Complexity in Congenital Heart Disease

Simple congenital heart disease •  Isolated congenital aortic or mitral valve disease •  Isolated patent foramen ovale or small atrial septal

defect •  Isolated small ventricular septal defect without

associated lesions •  Mild pulmonic stenosis •  Previously ligated or occluded patent ductus arteriosus •  Repaired secundum or sinus venosus atrial septal defect

without residua •  Repaired ventricular septal defect without residua

Categories of Disease Complexity in Congenital Heart Disease

Moderate severity congenital heart disease •  Aorto-left ventricular fistulae •  Total or partial anomalous pulmonary venous return •  Partial or complete atrioventricular canal defects •  Coarctation of the aorta •  Ebstein’s anomaly •  Infundibular right ventricular outflow obstruction of significance •  Ostium primum or sinus venosus atrial septal defect •  Patent ductus arteriosus (not closed) •  Moderate–severe pulmonic valve regurgitation •  Sinus of Valsalva fistula/aneurysm •  Subvalvular or supravalvular aortic stenosis (except HOCM) •  Tetralogy of Fallot •  Ventricular septal defect with absent valve(s), aortic regurgitation,

coarctation, mitral disease, right ventricular outflow obstruction, straddling tricuspid/mitral valve, or subaortic stenosis

Categories of Disease Complexity in Congenital Heart Disease

Congenital heart disease of great complexity •  Conduits (valved or nonvalved) •  Cyanotic congenital heart disease (all forms) •  Double-outlet ventricle •  Eisenmenger syndrome •  Fontan procedure •  Mitral or tricuspid atresia •  Single ventricle •  Pulmonary atresia (all forms) •  Pulmonary vascular obstructive diseases •  Transposition of the great arteries •  Truncus arteriosus/hemitruncus •  Other abnormalities of atrioventricular or ventriculoarterial connection

(crisscross heart, isomerism, heterotaxy syndromes ventricular inversion)

Reponse 2

Comment stratifier, quoi recommander?

Question 3

Prerequisites, general recommendations, and contraindications to high altitude

exposure

General prerequisites at low altitude •  Stable clinical condition •  Asymptomatic at rest •  Functional class < II NYHA

Prerequisites, general recommendations, and contraindications to high altitude

exposure General recommendations at high altitude •  Ascent at a slow rate > 2000 m (increasing

sleeping altitude by < 300 m/d) •  Avoid overexertion •  Avoid direct transportation to an altitude >

3000 m

Prerequisites, general recommendations, and contraindications to high altitude

exposure Absolute contraindications to high altitude exposure •  Unstable clinical condition, ie,

- unstable angina - symptoms or signs of ischemia during exercise testing at low to

•  moderate workload (<80 W or <5 metabolic equivalents) - decompensated heart failure - uncontrolled atrial or ventricular arrhythmia

•  Myocardial infarction and/or coronary revascularization in the past 3-6 mo

•  Decompensated heart failure during the past 3 mo •  Poorly controlled arterial hypertension (blood pressure ≥ 160/100

mm Hg at rest, > 220 mm Hg systolic blood pressure during exercise)

Prerequisites, general recommendations, and contraindications to high altitude

exposure Absolute contraindications to high altitude exposure (suite) •  Marked pulmonary hypertension (mean pulmonary artery pressure >

30 mm Hg, RV-RA gradient > 40 mm Hg) and/or any pulmonary hypertension associated with functional class ≥ II and/or presence of markers of poor prognosis37

•  Severe valvular heart disease, even if asymptomatic •  Thromboembolic event during the past 3 mo •  Cyanotic or severe acyanotic congenital heart disease •  ICD implantation or ICD intervention for ventricular arrhythmias in

the past 3-6 mo •  Stroke, transient ischemic attack, or cerebral hemorrhage during the

past 3-6 mo

Recommendations and preexposure assessment according to CV disease

Clinical Condition Proposed Preexposure Assessment and Recommendations for patients

Arterial hypertension If not well controlled → ambulatory blood pressure recording Instructions for self-monitoring of blood pressure and treatment adjustments if uncontrolled hypertension or hypotension develops

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Maladie coronarienne et la haute altitude

•  ↓ du risque MCAS et IM chez les résidents haute altitude

•  Vasoconstriction coronarienne possible en présence de dysfonction endothéliale et MCAS

•  Hypoxémie = moins stressant pour le cœur que l’exercice

•  Le rôle de l’hypoxémie souvent combinée avec l’exercice intense, le froid et le stress émotionnel

Recommendations and preexposure assessment according to CV disease

Clinical Condition Proposed Preexposure Assessment and Recommendations for patients

CAD Asymptomatic revascularization < 6 mo

Asymptomatic revascularization > 6 mo

Asymptomatic reduced LVEF

Consider exercise testing according to coronary status Exercise testing If not conclusive → exercise testing with imaging modality Exercise testing If not conclusive → exercise testing with imaging modality Transthoracic echocardiography at rest

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Évaluation du patient à risque CV

•  Épreuve d’effort (capacité maximale, récupération FC 1 et 2 min)

•  Épreuve d’effort avec analyses des gaz expiratoires •  Épreuve d’effort avec MIBI ou échocardiographie •  CCTA (Angio IRM) •  Angiographie coronarienne •  Holter ou cardiomémo ?

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L’altitude contribue-t-elle à la décompensation du patient insuffisant cardiaque ?

•  L’ascension est sécuritaire jusqu’à 2,500 mètres chez le patient bien compensé

•  Il y aurait rétention hydrosodée associé à l’AMS rendant le patient défaillant plus à risque

•  La majoration des diurétiques, le diamox, sildenafil sont à considérer

•  Ajustement de la médication concomitante ?

Recommendations and preexposure assessment according to CV disease

Clinical Condition Proposed Preexposure Assessment and Recommendations for patients

Reduced LVEF Any cause

Exercise testing Transthoracic echocardiography at rest Instructions for treatment adjustments if heart failure develops

Recommendations and preexposure assessment according to CV disease

Clinical Condition Proposed Preexposure Assessment and Recommendations for patients

Pulmonary hypertension Exposure contraindicated if marked pulmonary hypertension or if functional class > I (see Table 2) Echocardiographic assessment of RV function and of pulmonary artery pressure under simulated high altitude (FIO2: 12%; if RV-RA gradient > 40 mm Hg patients should be strongly discouraged)

Recommendations and preexposure assessment according to CV disease

Clinical Condition Proposed Preexposure Assessment and Recommendations for patients

Valvular heart disease Symptomatic and/or severe Mild aortic or mitral regurgitation

Exposure contraindicated Exercise testing, transthoracic echocardiography at rest Instructions for self-monitoring of blood pressure and treatment adjustments if uncontrolled hypertension or hypotension develops Instructions for self-monitoring of international normalized ratio and dosis adaptation

Recommendations and preexposure assessment according to CV disease

Clinical Condition Proposed Preexposure Assessment and Recommendations for patients

Congenital heart disease Acyanotic or cyanotic Exposure contraindicated if functional

class > I Exercise testing and echocardiographic assessment of left and RV function and pulmonary pressure under simulated high altitude (FIO2, 12%; if RV-RA gradient > 40 mm Hg patients should be strongly discouraged)

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La haute altitude provoque-t-elle des arythmies cardiaques ?

•  ESV ↑ de 63% en réponse à l’ascension rapide. Ceci est couplé d’une ↑ de norepinéphrine de 67%.

•  Impact de l’altitude sur les arythmies supra ventriculaires indépendamment de l’effort et de la température froide demeure inconnu

Recommendations and preexposure assessment according to CV disease

Clinical Condition Proposed Preexposure Assessment and Recommendations for patients

Arrhythmia Associated with CAD/CHF Pacemaker

Supraventricular tachycardia/atrial flutter

Paroxysmal or persistent atrial fibrillation

Exercise testing Testing only if VVIR, DDDR, or AAIR mode to adapt PM rates Consider catheter ablation before high-altitude exposure Exercise testing and Holter-ECG Instruction for heart rate self-monitoring and therapy adjustments in case of insufficient rate control (>90 beats per min at rest)

Clinical Condition Proposed Preexposure Assessment and

Recommendations for patients Cerebrovascular disease All conditions Ischemic stroke or TIA b 90 d ago

Ischemic stroke or TIA N 90 d ago, thorough workup of the stroke has been performed and risk factors are treated adequately

Stenosis or occlusion of a major extra- or intracranial cerebral artery

Hypertensive hemorrhage

Hemorrhage as a result of amyloid angiopathy Known cerebral aneuryms, arteriovenous malformation, or cerebral cavernoma

Avoid trekking or climbing alone Avoid traveling to higher altitudes (>2000-2500 m) Avoid air travel Avoid extreme altitude > 4500 m

Avoid traveling to altitude > 2000-2500 m

Travel to high altitude only if blood pressure is controlled and not before 90 d after the event Avoid high altitude Check blood pressure. Avoid extreme altitude > 4500 m

Recommendations and preexposure assessment according

to CV disease

51

Facing our limits 6120m

MW 03-2007

Capacite physique requise pour la haute montagne

•  Endurance musculaire et cardiovasculaire •  Capacitee de travailler sans oxygene – amelioration du

seuil ventilatoire •  Force exceptionelle au niveau des cuisses, dos et epaules •  Stabilisation au niveau du “core” •  Bonne flexibilitee •  Capacitee de relaxation

“There are three kinds of lies: lies, damned lies, and statistics”

MW 2002-03

Links between physiologic systems and the sources

of perceived sensation limiting exercise in humans Motor command

Excitation - contraction (Na+ - K+)

Cross-bridge formation (Ca2+)

Glycogen + ADP → ATP + Lactate + H+

Glycogen + ADP + O2 → ATP + CO2

FFA + ADP + O2 → ATP + CO2

Process

Brain

System

Effort

Sensation

Power output (ATP → ADP)

Nerve Weakness

Muscle Tension

Metabolism Fatigue

Blood flow

Ventilation O2 CO2

Circulation

Lungs Epstein FH, NEJM 2000; 31: 632-641

Relationship between mitochondrial volume and number of capillaries in humans

Esposito F, at al. J Am Coll Cardiol 2010;55:1945-54

MW 2003

Exercise conditioning training improves submaximal exercise capacity in older CAD patients

Ades PA et al. Circulation 1993; 88: 572-577

Rest HR Systolic BB

Low submaximal exercise Intensity (% VO2 max) HR Serum lactate Perceived exertion

High submaximal exercise Intensity (% VO2 max) HR Serum lactate Perceived exertion

Submaximal exercise duration Mean exercise time (min) Complete 45-min protocol

70 ± 16 135 ± 25

58 ± 17% 94 ± 16

1.85 ± 0.96 9.9 ± 2.6

79 ± 14% 108 ± 16

2.30 ± 1.08 14.0 ± 2.2

30 ± 10 10/45 (22%)

Baseline (n = 45)

68 ± 14 134 ± 21

50 ± 8* 84 ± 12

1.44 ± 0.46* 8.7 ± 2.2*

67 ± 10%* 97 ± 16*

1.60 ± 0.43* 11.7 ± 2.2*

41 ± 10* 33/43 (77%)*

3 months conditioning

(n = 43)

68 ± 1* 122 ± 20*†

46 ± 7* 84 ± 10*

1.39 ± 0.26* 7.9 ± 1.2*

55 ± 12%*† 97 ± 10*

1.60 ± 0.41* 11.5 ± 2.5*

43 ± 7* 10/11 (91%)*

12 months conditioning

(n = 11)

* p < 0.05 vs baseline † p < 0.05 vs 3 months’ conditioning

Reponse 3

MW 2008-01 58

Le patient à bas risque

•  Hypertension artérielle traitée •  Patients diabétiques •  Sujets «jeunes» ou «âgés» •  Maladies coronariennes athérosclérotiques minimes •  Statut post-dilatation coronarienne ou pontages

aorto-coronariens •  Statut post infarctus du myocarde sans dysfonction

ventriculaire gauche résiduelle

MW 2008-01 59

Le patient à risque modéré

•  Angine d’effort stable avec seuil ischémique élevé •  Maladie coronarienne athérosclérotique documentée

(uni ou bi tronculaire) •  Dysfonction ventriculaire gauche asymptomatique

(FEVG ≥40%) •  Hypertension artérielle labile •  Arythmie supra-ventriculaire ou ventriculaire traitées

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Le patient à risque élevé

•  Ces patients devraient vraisemblablement s’abstenir d’une exposition et une altitude modérée (1000- 2500 m) ─  Patients porteurs de cardiopathie cyanogène ─  Toute forme d’hypertension artérielle pulmonaire ─  Dysfonction ventriculaire gauche avec F.E. à 40% ─  Hypertension artérielle mal contrôlée ─  Maladie coronarienne athérosclérotique de plusieurs

troncs vasculaires avec seuil ischémique bas ─  Arythmie cardiaque mal controlée

Quoi faire avec la RX cardiovasculaire?

Question 4

Medication for the prevention and treatment of AMS

PDE5Is for HAPE and HAPH

BP reduction with PDE5Is

Reponse 4